Hospital emergency departments are for conditions that meet the layperson's definition of emergency. For urgent conditions that do not meet the layperson's definition of an emergency, all EmblemHealth plan members have access to network urgent care centers.

Urgent care centers enable members to receive the care they need in a more expeditious manner, eliminating long waits in emergency rooms. To facilitate continuity of care, PCPs are advised of member visits to participating urgent care centers. A copy of the encounter record and any test results will be provided to the PCP.

We encourage physicians to refer our members to network urgent care centers for urgent care when the physician or covering physician is not available. All non-urgent care services should be referred back to the member's PCP.

Vytra members should visit www.vytra.com or call the Vytra Customer Service line at 1-866-409-0999.

URGENT AND IMMEDIATE CARE PROVIDERS

Category

Details

Retail Convenience Health Clinic

These are quick access clinics staffed by nurse practitioners (NPs), physician assistants (PAs) and sometimes physicians and designed to offer immediate, limited in-scope treatment for health conditions that are not severe enough to require services in an urgent care or emergency care setting.

These clinics are typically located in retail stores and offer members a lower cost alternative. Common conditions treated include sore throats, sprains, strains and colds. For example, members may choose to visit either a MinuteClinic or DR Walk-in Medical Care clinic for treatment.

Walk-In Medical Office

No appointment necessary. A practice that treats patients without requiring them to be an existing patient or having an appointment and that can provide routine primary care and immediate treatment of common family illnesses for adults and/or children.

Urgent Care Center

These medical facilities offer immediate evaluation and treatment for health conditions that are not severe enough to require treatment in the hospital or a hospital emergency room. Billed place of service (POS) 20. Conditions treated through urgent care centers include common medical ailments such as sore throats, flu, earaches, respiratory infections, small cuts, sprains and minor broken bones.

Urgent care centers provide care and treatment through qualified physicians, PAs and NPs when care needs fall outside of the physician's regular office hours or before an appointment is available with a primary physician. Emergency room copays can be three to five times as much as a standard office visit, so visiting an urgent care center offers members lower copays and lower overall care costs.

When EmblemHealth plan members or their children 18 months or older need to see a health care provider for a minor ailment, such as an ear infection, allergies, bronchitis, or strep throat, they may choose to visit a MinuteClinic or DR Walk-in Medical Care clinics for treatment.

MinuteClinics are owned by CVS Corporation and accredited by The Joint Commission. DR Walk-in Medical Care is owned by Duane Reade, a Walgreen's company. There are nationally-based MinuteClinics in CVS pharmacies and other retail locations. DR Walk-in Medical Care is located in New York City-based clinics in seven Duane Reade pharmacies.

These clinics are providers of "retail-based" health care and offer quick and convenient (no appointment required) health care during business hours, many with seven days a week and extended hour service. MinuteClinics are staffed by certified advanced practice nurse practitioners and DR Walk-in Medical Care is staffed with licensed medical doctors. They offer treatment for common family illnesses, as well as vaccinations.

They are intended to be a complement to, not a replacement for, our members' ongoing relationship with their PCP. We encourage members to have these clinics send their medical records to their PCP to ensure continuity of care. The clinic practitioners also stress that patients should obtain a regular medical exam from their PCP.

Copays for visiting these clinics are determined by the terms of the member's individual health insurance plan and would be equivalent to the member's copay for a PCP visit.

MinuteClinic has many locations in EmblemHealth's service area. EmblemHealth plan members may also be treated at MinuteClinic locations throughout the United States. To find a convenient location, members may visit the MinuteClinic website at www.minuteclinic.com or call them at 1-866-389-2727.

Please note that visits to a DR Walk-in Medical Care facility do not require a referral.

Glossary terms found on this page:

An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

A licensed doctor of medicine or osteopathy who has an agreement with a network provider to provide covered services to members when the network provider is not available.

Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

Care for a person with an emergency condition.

A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery

Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry

Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff

Maintains medical records for all patients

Has a requirement that every patient be under the care of a member of the medical staff

Provides 24-hour patient services

Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

Doctor of medicine

Doctor of osteopathy

Dentist

Chiropractor

Doctor of podiatric medicine

Physical therapist

Nurse midwife

Certified and registered psychologist

Certified and qualified social worker

Optometrist

Nurse anesthetist

Speech-language pathologist

Audiologist

Clinical laboratory

Screening center

General hospital

Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.